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61 Cards in this Set
- Front
- Back
Nurses role in the preoperative phase
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-Patient and family education
-Thorough assessment -Prepares pt. for OR -Administration of medications -Documentation |
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Preadmission phase
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-Begins at MD office
*Medical Hx within 30 days -Preadmission testing *Labs within 7 days (if >60yoa) *EKG withing 90 days (if >45yoa) -Nursing Hx (in person or over phone) -Pre-op teaching -Special instructions -Special Consents -Anesthesia Evaluation |
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Pre-Op Phase
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-Nursing Assessment
-Physical preparation -Complete pre-op checklist -emotional/psychological concerns -Reinforce &/or initiate pt teaching -Document everything! |
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Patient's psychological response to surgery
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Pre-operative fear/anxiety r/t unknown outcome of surgery, possible death, pain, loss of work time, perceived burden on family, permanent incapacity
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Patient's physiological response to surgery
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Fill in later
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Spiritual and Cultural Beliefs and Surgery
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-Play role in how pt copes with fear and anxiety
-Pt's beliefs should be respected and supported -Spiritual help should be obtained if requested by pt |
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Nutritional Status and surgery
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-Helps promote healing and resisting infection
-The body has an increased need for: *protein: tissue repair *calories: *water: replace lost fluid, maintain homeostasis *Vit C: capillary fx, wound healing *Vit A: immune system, tissue repair *Vit K: normal blood clotting *iron: replace iron lost through blood *zinc: protein synthesis & wound healng |
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NPO status before surgery
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-To prevent aspiration during surgery
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Lab Values:
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RBC: 5-10
WBC: 5 - 10 (infection) Hgb: m: 13.5-18 f: 12-16 (anemia, GI bleed) HcH: m: 40-54% f: 38-47% U.A.: 2.5-6.0 (dehydration) BUN: 6-20 (Dehydration, GI bleed) Creatine: m: .6-1.3 f: .5-1.0 (dehydration) |
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Nurse's fx after admin of sedative pre-op
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-Before giving the nurse should allow pt to void
-Assess vital signs -Pt safety: side rails up... -Room should be quiet to allow for relaxation |
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Major areas to check on preoperative checklist
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-Patient allergies
-Consent forms w/ signatures -Lab report/EKG report -Med sheets -Pt admission assessment |
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Why all routine and PRN meds are stopped when pt goes to surgery
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-Because of the possible effects of medication on the pt's peri-op and perianesthesia and possible drug interactions
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Benefits to pre-op teaching
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-Reduced fear and anxiety
-Empowers pt to become active participant -Decreased post-op vomiting, pain, and need for analgesia -Shorten hospital and recovery time -Enhances coping mechanisms -Increases surgical experience |
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Principles of teaching that should be utilized
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-Motivation
-Readiness to learn -Active involvement -Feedback (reinforces learning) -Organizing logically -Relating to prior experience -Match pt's learning style -Short learning and application time -Assess environmental factors |
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Information that should be included during pre-op teaching
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-Time of surgery
-Food and fluid restrictions -Informed consent -Physical preparation (enemas, IVs...) -Intraoperative expectations |
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Three Domains of learning (B. Bloom)
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-Cognitive domain: involves knowledge & the development of intellectual skills. This includes the recall or recognition of specific facts
-Affective domain: includes the manner in which we deal with things emotionally, such as feelings, values, appreciation, enthusiasms, motivation, & attitudes. -Psychomotor domain: includes physical movement, coordination, & use of the motor-skill areas. |
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4 physical changes that effect learning in the older adult pt
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-Sensory: vision, hearing, touch, and smell
-Motor control: decreased muscle strength, loss of flexibility, & endurance -Nervous System: reduced speed of nerve control, conduction, confusion, slow response and reaction time -Memory Loss: slow recall or poor short-term memory -Nursing Interventions: -Set achievable goals -Use visual aids in large print -Increase teaching time -Allow for rest periods -Repeat information -Use prior experience, examples the pt can relate to -Teach in a quiet environment, comfortable to the pt |
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Complications of positioning
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-Undue pressure on a body part should not obstruct vascular supply (postural hypertension, venous pooling, compartment syndrome)
-Respiratoin should not be impeded by pressure of arms on chest (dyspnea) -Nerves must be protected from undue pressure, improper positioning can cause serious injury or paralysis (injury of brachial, ulnar, radial, sciatic, tibial, or peroneal nerves) -Integumentary breakdown of the skin and scalp (alopecia) -Reproductive (genital injury) -Sensory effects (corneal abrasion, conjunctival edema, ear injury) -Skeletal (aseptic necorsis of femoral head, fx of symphysis pubis) -Muscular pain in lumbar, neck, and shoulders -Precautions for pt safety for thin/elderly, obese and pts with deformities or handicaps |
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Surgical Asepsis
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Absence of microorganisms in the surgical environment to reduce th risk for infection
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Intra-operative heat loss and hypothermia
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During anesthesia, pt's temp may drop:
-Reduced glucose metabolism may cause metabolic acidosis -Core temp: < 98.0 Caused by: *low OR temp *infusion of cold fluids *inhalation of cold gases *open wounds or body cavaties *decreased muscle activity *advanced age *pharmaceutical agents |
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Signs and symptoms of malignant hypothermia
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-Inherited muscle disorder chemically induced by anesthetic agents
-Tachycardia -Ventricular dysrhythmia -Hypotension -Decreased cardiac output -Oliguria (decreased urine volume) -Abnormal transport of calcium causes: *tetanus like movements (often in jaw) *rigidity -Late sign: rapid increase in temperature |
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Precautions taken by OR team to prevent medical-legal problems
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-Check patient's ID band
-Have state and spell full name and date-of-birth -Ask pt to list any allergies -Mark the site on the patient -All instruments to be used during the surgery are counted and documented on the white board before the surgery and again at the end of the surgery |
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Regional Anesthesia
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-The temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body
-Epidural -Spinal -Caudal -Nerve block |
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Epidural
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-An injectin into the the epidural space inside the spinal column (not in the dura mater)
-Will have a higher dosage than spinal because doesn't make direct contact with spinal cord or nerve roots |
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Spinal
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-aka subarachnoid block
-lumbar puncture between L4 or L5 or S1 -Injected into subarachnoid space |
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Caudal
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-aka transsacral
-produces anesthesia of the perineum and occasionally the lower abdomen |
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Nerve Block
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-A technique in which the anesthetic agent is injected into and around a nerve or small group of nerves
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Advantages of using spinal or epidural rather than general anesthesia
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-Patient awake with spinal/epidural
-Minimal effect on respiratory and CV systems -Decreased recovery time -Prolonged analgesic effect post-op |
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Reasons for using epinephrine with local anesthetics
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-It contricts blood vessels, which prevents rapid absorption of anesthetic
-Prolongs local action -Prevents seizures |
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Conscious Sedation
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Will fill in later
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Post-op Urine output
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-Anesthetics, anticholinergic agents and opiods interfere with perception of bladder fullness and inhibit the ability to void within the 8 hours of surgery
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Progressive Diet
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will fill in later
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Corticosteroids
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-Ex: prednisone
-Interaction: Cardiovascular collapse can occur if d/c'd suddenly -A bolus may be given before and right after surgery |
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Diuretics
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-Ex: hydroDIURIL
-Interaction: may cause respiratory depression resulting from an electrolyte imbalance |
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Phenothiazines
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-Ex: Thorazine
-Interaction: may increase hypotension action of anesthetics |
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Tranquilizers
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-Ex: Diazepam (valium)
-Interaction: may cause anxiety, tension, and seizures if withdrawn suddenly |
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Antibiotics
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-Ex: erythromycin
-Interaction: When combined with a curariform muscle relaxant, nerve transmission is interupted and apnea from respiratory paralysis may result |
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Antisezuire
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-Ex: phenttoin (dilantin)
-Interaction: may need to be administered IV to keep pt from having seizure during surgery |
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Monoamine Oxidase (MAO) inhibitor
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May increase the hypotensive action of anesthetics
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Informed Consent
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Voluntary and written:
-must be freely given, without coercion -Should contain explanation of surgery, description of benefits and alternatives, an offer to answer questoins , Instructions that inform pt that they may withdraw consent, a statement informing pt if the protocol differs from customary procedure -Important: protects the pt from unsanctioned surgery and protects the surgeon from claims of of an unauthorized operation |
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Suffixes used
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-ectomy: removal of
-lysis: destruction of -orrhaphy: repair or suture of -oscopy: looking into -ostomy: creation of opening into -plasty: repair or reconstruction |
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Wound healing: Primary
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-Wound is clean in a straight line, with little loss of tissue
-All wound edges are well approximated with sutures -Usually rapid healing with minimal scarring |
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Wound Healing: secondary
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-Large wound with considerable tissue loss
-Natural healing by formation of granulation tissue -Healing takes longer and results in more scarring |
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Wound Healing: Tertiary
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-Time delay before wound is sutured
-Greater granulation, risk of infection, inflammatory reaction than primary intention -Late suturing and more scaring |
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Factors affcting Wound Healing
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-Good handwashing
-Diet: vit C and protein -Adequate hydration -medications -Splint incision when CDB -Type and location -Pt age -Other medical Dx -Lifestyle factors |
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Phases of wound healing
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-Inflammation:
*1-7 days *WBC, clot formation, cell migration -Proliferation: *7-30 days *new tissue, granulation, diet important -Maturation *21 days to several months (even years) *tissue strengthens, scar is reduced |
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Terms R/T Wound Healing
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-Granulation: migration of fibroblasts with secretion of collagen and new capillary formation (wound is fragile and bleeds easily)
-Eschar: thick necrotic tissue (may be white, black, or gray) -Debridement: removal of non-viable tissue (may be done surgically or mechanically) |
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Problems Interfering with Wound Healing
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-Dehiscence: partial or complete seperation of wound edges
-Evisceration: dehiscence with abdominal contents protruding from wound -Infection: characterized by increased temp of surronding tissues, swelling, redness, purulent drainage; Dx with wound culture, increased WBC |
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Deep Vein Thrombosis
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-Risk factors: dehydration, decreased cardiac output, venous pooling, bedrest, and hypercoagulability, history of oral contraceptives
-S/S: + homan's test, edema, increased temp & HR, chills, redness, cramps -Prevention: leg exercises, AE or pneumatic hose, early ambulation, adequate hydration |
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Pulmonary Embolism
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-DVT breaks loose and moves to pulmonary artery
-May be mild or severe -Mild = vague S/S *Dyspnea, mild substernal pain, cough-hemoptysis, increased resp rate & HR -Sever = acute S/S *Sudden, sharp, stabbing substernal pain *pulse is rapid, weak, thready, cyanosis |
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Nursing Management of DVT & PE
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-Pt placed on bedrest
-Ensure adaquate hydration -Anticoagulant therapy initiated -With DVT, goal is to prevent PE -Administer oxygen -With PE goal is to ensure adequate oxygenation & prevent resp distress &/or resp arrest **Early ambulation key to prevention |
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Common Pre-operative Meds
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-Histamine Antigonists/Antiulcer
*Zantac/ranitidine -Anti-emetics *Reglan, Zofran -Alkalinizing agent *Sodium Citrate: prevents aspiration -Opioids/Analgesics *Demerol, methadone -Sedatives/Hypotonics/Anti-anxiety *Ativan, Halcion, Valium, Xanax |
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Acute Pain
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-Recent onset
-Associated with specific injury -Defined as lasting from a few seconds to up to 6 months |
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Chronic Pain
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-Constant or intermitten
-Persists over time -Difficult to treat -Lasts > 6 hours -Serves no useful purpose -Leads to: depression, irritability, disturbed sleep, loss of libido, and appetite |
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Assessing Pain
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-Basic parameters: location, intensity, quality, chronology, other sx
-Tools for assessing: intensity rating scales, physiologic indicators, behavioural responses -Factors influencing pain response: past experiences, age, depression, anxiety, culture, ethnicity |
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Pain Management
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-Narcotics: work on CNS, side effects: N/V, constipation, sedation, tolerance, resp. depression, urinary retention
-Non narcotics: work on peripheral nervous system, anti-inflammatory |
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Respiration Management
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-hypoventilation leads to atelectasis, pneumonia
-Increased risk: thoracic and upper abdominal surgeries, elderly or obese -Check resp. rate and lung sounds -Encourage DB and voldyne use -Evaluate effect of meds on resp. -Evaluate need for O2 -Increased temp may indicate increased secretions -Important 24-36 hours after surgery: deep breathing and couging |
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Shock
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-A condition in which systemic BP is inadequate to deliver O2 to vital organs
-Untreated can result in cell starvation and organ dysfunction -Can progress to organ failure and death -Adequate blood flow requires: *adequate cardiac pump *effective circulatory system (blood vessels) *adequate blood volume *adequate CBC and hemaglobin capacity |
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Types of Shock
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-Hypovolemic: decreased blood volume
-Cardiogenic: decreased pumping ability -Distributive/vasogenic: blood vessels -Neurogenic: massive vasodilation r/t loss of sympathetic tone -Anaphylactic: massive vasodilation and capillary permeability r/t allergic reaction -Septic: maldistribution of blood volume and decreased myocardial Fx r/t overwhelming infection *Three causes: -Heart, Blood, Blood vessels |
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S/S of shock
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-Feeling of anxiety
-Pallor with color, clammy skin -Nervousness, apprehension, confusion -Comabtiveness -Rapid, shallow respirations -Increased pulse -BP WNL at first then decreases -Hypoactive bowel sounds -Conc. Urine or no urine output -change in LOC -Labs: low O2 sat and H&H |
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Management of Shock
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-Early intervention is key
-Give oxygen to counteract hypoxemia -Trendelenburg position (except in neurogenic) -Treat cause: stop bleeding, replace fluids -Administer meds: -Keep warm -Frequent VS |